Transcript Intro QALY & need assessment

QALY: veel bekritiseerd, maar nooit
meer dan het alternatief”
Symposium “De validiteit van de QALY”
14 maart 2008
NVTAG, RIVM, Bilthoven
Jan van Busschbach
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QALY seem to survived criticism
for years now….
 QALY
is difficult to appreciated….
 but in 2007: 4150 Citations in PubMed
 Could it be that there is a flaw in the criticism?
1980[pdat] AND (QALY or QALYs)
600
Publications
500
400
300
200
100
0
1980
1985
1990
1995
2000
2005
2010
2
Three problems with the criticism …..
1.
2.
3.
Argument often represent aversion limited budget
Proposed alternatives turn out the be the same
Even equity concerns are in need of QALY
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First critique
 1983
Cohen C.B.
 1989
Rawles
 Quality of life and the analogy with the Nazis.
 Journal of Medicine and Philosophy 8: 113-35
 Castigating QALYs [Debate].
 Journal of Medical Ethics 15:143-7
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First outcome discussion
 Rawles
J., Rawles K.
 The QALY argument: a physician's and a philosopher's view.
 Journal of Medical Ethics 16: 93-4, 1990
“… In spite of the rhetoric there is a broad measure of
agreement about the deficiencies of QALYs as a means of
distributing scarce resources….”
“…The main area of conflict is that John Rawles favours
campaigning for more resources while Gavin Mooney,
constrained by his remit as a health economist, favours
acceptance of the present level of funding and better methods
of distributing resources.” (blz. 93)
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Positions
 Pro
 Budget is limited
 QALY might be a solution
• Although not perfect….
 Contra
 Budget is not yet limited
 QALY is not perfect
• QALY is a problem
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Positions still apply…
 2007:
Kees van Bezooijen
 Patient representative
 In discussion during introduction cost effectiveness parameter in
reimbursement expensive hospital medications
“…Wij hebben duidelijk aangegeven dat een discussie over "wat
maatschappelijk nog aanvaardbaar is" [kosten per QALY] alleen
gevoerd mag worden als geldverslindende "frivoliteiten" door de
maatschappij […] zijn uitgebannen. Bijvoorbeeld "joint strike
fighters“…
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A limited budget is reality
 There
is no prominent school of though that
advocates that the budget is unlimited
 A limited budget is the norm
 Unlimited is not a realistic position
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Three problems with the criticism …..
1.
2.
3.
Argument often represent aversion limited budget
Proposed alternatives turn out the be the same
Even equity concerns are in need of QALY
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Neil Aaronson, 1996
 QALY
is a the wrong answer for a very complex
process….
 We are in need of a robust, simple and new
method….
 TWiST
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Time Without Symptoms of disease and
subjective Toxic effects of treatment
 TWiST
 Developed by Richard Gelber (statistician)
 In
search for a typical “cancer” problem
 Often prolonged life but also a reductions in quality of

life
• At the beginning (side effects)
• At the end
Only count the days without symptoms of disease and
subjective toxic effects of the treatment
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TWiST in cancer therapy
180
Average number of TWiST's
160
140
120
100
Drug
Placebo
80
60
40
20
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
First Year of treatment
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TWiST: ignores differences
in quality of life
 TWiST
 Healthy = 1
 Sick (dead) = 0
 There
is more to life than sick/health
 Make intermediate values of quality of life
 Q-TWiST
• Quality of life adjusted TWiST
 But
then: 365 x Q-TWiST = 1 x QALY
 Thus alternative is just the same
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Burden of Disease Project
 WHO
Global Burden of Disease (GBD)
 Impact of diseases world wide
 Estimates of epidemiology per disease
 Mortality
 Quality of life losses
 In
need of one measure of health
 But WHO disliked QALY…
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Chris Murray
 Havard
 School of Public Health
 Worked
outside
 Health economics
 Med Decision Making
 DALY
 Disability Adjusted Life Years
 Lost life years
 Lost Quality of life
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DALY / QALY
1
Adjusment factor
0.9
DALY
0.8
0.7
0.6
0.5
QALY
0.4
0.3
0.2
0.1
0
0
10
20
30
40
50
60
70
80
90
Life years
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Q-TWiST and DALY
 Both
are presented as alternatives for QALY
 But are in fact the same…
 See also
 Healthy Year Equivalent (HYE)
 Saved Young Life Equivalent (SAVE)
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Three problems with the criticism …..
1.
2.
3.
Argument often represent aversion limited budget
Proposed alternatives turn out the be the same
Even equity concerns are in need of QALY
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Efficiency / equity debate
 Cost
per QALY represents efficiency
 But is our health care system based on
efficiency?
 In health care, next to efficiency…
 Compassion
 Solidarity
 Commiseration
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Nord: “Egalitarian and efficiency concerns both exist …”
1.0
A
B
C
0.0
20
Nord: “Egalitarian and efficiency concerns both exist …”
1.0
A
B
C
0.0
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Nord: “Egalitarian and efficiency concerns both exist …”
1.0
A
B
C
0.0
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Several definition of equity
 Severity
of illness
 How bad is it now?
 Fair
innings
 How good has it been?
 In
all cases…. QALY is used to express equity
 “QALY equity” to correct “QALY efficiency”
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Dutch Council for Public Health and Health Care
(De Raad voor de Volksgezondheid en Zorg, 2006)
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Three problems with the criticism …..
2.
3.
Argument often represent aversion limited budget
Proposed alternatives turn out the be the same
Even equity concerns are in need of QALY
1980[pdat] AND (QALY or QALYs)
600
500
Publications
1.
400
300
200
100
0
1980
1985
1990
1995
2000
2005
2010
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First QALY
 1968
Klarman, Fransis & Rosenthal
 Cost effectiveness analysis applied to the treatment of chronic renal

disease
Medical Care 6: 48-54, 1968.
 1970
Fanshel & Bush
 A health-status index and its application to health services

outcomes.
Operations Research 18: 1021-66, 1970
 1976
Torrance
 Social Preferences for Health Status: an empirical evaluation of
three measurement techniques.
• Socio-Economic Planning Science 10: 129-36, 1976.
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